My Current Thoughts on the Treatment of Frozen Shoulder

Gary G. Poehling, MD

Wake Forest University Medical Center

Winston-Salem, N.C.

Definitions

Frozen Shoulder is defined by restriction of active and passive shoulder motion in all planes without a known specific cause.

Secondary Shoulder Stiffness when restricted motion is related to a known cause.

Historical Perspective

DATE-AUTHOR-CAUSE

1872-DuPlay-Subacromial Bursitis

1932-Pasteur-Biceps Tendonitis

1934-Codman-Tendonitis of Rotator Cuff “Frozen Shoulder”

1937-Meyers-Irregular Intertubercular Groove

1940-Bosworth-Subdeltoid Bursitis

1941-Lippman-Adhesions to Biceps

1945-J. Neviaser-Contracture of Capsule “Adhesive Capsulitis”

1952-DePalma-Coracohumeral Ligament and Biceps

1955-Bateman-Articular Recess Obliteration

1959-Charnley-Collagen Degeneration of Tendons

1961-DeSeze-Retraction of Joint Capsule

1963-Lindstrom-Adhesions Beneath the Coracoid

1969-Lundberg-Joint Contracture

1987-T. Neviaser-Diffuse Fibrinous Synovitis

1991-Wiley-Subscapular Bursal Contracture

Natural History

Common Perception —Self limited disorder generally lasting 12-18 months

1975 Reeves and 1978Grey in natural history studies have shown that resolution of frozen shoulder often take 2 to 3 years.

1992 Shaffer and Tibone reviewed 62 patients with frozen shoulder that were treated non-operatively and followed an average of 7 years. Ten patients had manipulations. Thirty-one patients (50%) reported the shoulder was painful or stiff or both. Sixty percent of patients had measurable restriction of motion.

Incidence

1995 Bunker 50/935 (4.70o) of shoulder referrals had frozen shoulder

Pathologic Basis

Cause Unknown

Inflammation plays a role

No common denominator

Diabetes

1. Increases risk if insulin dependent greater than 10 years

2. Poor prognosis

3. Slower recovery

Divided into three phases

1. Painful freezing from acute synovitis (3-9 months)

2. Frozen phase (4-12 months)

3. Thawing phase (12-42months)

Clinical Presentation

Insidious onset

Motion restricted in all planes

Isometric strength symmetric in all directions

Motion restricted 50-60 degrees

Crepitation Absent

X-ray normal slight osteoporosis in long standing cases

Results of Arthroscopic Treatment

1986 Ogilvie-Harris and Wiley

1. Eighty one patients with frozen shoulder average follow up 4 years

2. All treated with manipulation and diagnostic arthroscopy

3. Recovery more rapid with this regime

4. Eleven diabetic patients had less satisfactory results

1991 Wiley

1. Reports on arthroscopic appearance of frozen shoulder

2. No infraglenoid recess obliteration

3. Patchy vascular reaction

4. Adhesions in the subscapular bursa

5. Striking pain relief with diagnostic arthroscopy and manipulation

6. Half of the patients experienced protracted recovery 6-30 months

1993 Harryman

1. Described the technique of arthroscopic capsular release

2. Reported on 7 cases — 3 were diabetic

3. All improved and returned to employment

1994 Pollock

1. Reported on 30 patients treated with scalene block, manipulation, and arthroscopic debridement of the joint and subacromial space.

2. Overall 83% had satisfactory results

3. Diabetics had only 64% satisfactory results

1995 Ogilvie-Harris

1. Compared 18 patients with arthroscopy before and after manipulation to 20 patients treated with arthroscopic release

2. Manipulation group had 7/18 excellent results

3. Arthroscopic release group had 15/20 excellent results

1996 Beaufils

1. Reported on 26 patients with shoulder stiffness treated by arthroscopic release.

2. Indications are for patients with significant decreased range of motion

1996 Warner

1. Reported on 23 patients with refractory adhesive capsulitis

2. Concluded — motion reliably improves with little morbidity

1997 Harryman

1. Reported on 30 cases of arthroscopic capsular release

2. The technique of complete capsular release using a basket forceps is described Diabetics accounted for 13/30 patients there recovery was slower but in the end had results equal to non diabetics

3. Both groups had 88% good or excellent results

1997 Ogilvie-Harris

1. Reported on 17 diabetic patients with shoulder stiffness treated by arthroscopic capsular release

2. Excellent results 13/17 (76%)

3. Good results 3/17(18%)

4. Poor results 1/17(6%)

My Current Approach

Many patients respond to aggressive physical therapy, steroid injection and time

For those that do not respond in 3-6 months

1. Arthroscopy is an efficient diagnostic tool

2. Has the opportunity to correct the pathology

Capsular release will yield

1. Improvement in 80-90 % of cases

2. Low morbidity

3. Rapid rehabilitation

Conclusion

Arthroscopic capsular release as described by Harryman is a major advancement in the treatment of frozen shoulder and stiffness.